Board-Certified Ophthalmologist

Phone 503.581.5287  
Fax  503.386.1377  
CATARACT PRE-OP & POST-OP INSTRUCTIONS

Prior to Surgery
Please bring these items to surgery
Fill all medication eye drop prescriptions at your pharmacy.
Start all drops as directed 1 day before surgery.
Arrange for a driver to bring you to and from your surgery appointment.

We ask that only one person accompany you to the surgery center.
And that you arrive no earlier than your scheduled time of:
Day
Date
Time
You will be at the surgery center for approximately 1 hour and 30 minutes,
from check-in to discharge.


The Night Before
Make sure to shower,
wash hair and face.
Eat and drink as usual. Take all medications unless otherwise instructed by your surgeon.

Notes


Independent Physician at Medical Center Eye Clinic
655 Medical Center Drive NE
Salem, OR. 97301
Page 1



Day of Surgery
Be careful of your eye(s). Do not rub, bump, touch, or squeeze your eyelid(s).
Nothing by mouth two hours prior to your procedure. May take medications with very small sips of water.
Absolutely no alcohol or marijuana the day of your surgery.
No earrings or face jewelry. Remove and leave all jewelry at home. Medical alert tags and wedding rings are OK.
Wear loose clothes and short sleeves. Slacks are suggested for ladies. Tennis shoes or similar types of rubber-soled shoes are requested for your safety.
Do not wear make-up, face or body lotions, perfume or cologne. No scented or alcohol- based products on your hair or skin, including:
If you are an insulin-taking diabetic, please be sure to eat, take your insulin, test your blood sugar and write the results on a piece of paper to give to your nurse at the surgery center. Start all drops as directed 1 day before surgery.
No hairspray, mousse, gel, detangler, leave-in- conditioner, etc. No deodorant or antiperspirant, shave gel, after shave, mouthwash, mints, etc. These products are prohibited as they can damage the ultra-sensitive laser optics.
You will be sent home from surgery wearing a plastic shield to protect your eye. Your surgeon will remove it at your 1 day post-op appointment. Do continue using your prescribed eye drops as directed when you get home in your surgery eye only.
Please bring to surgery: your glass case if you wear glasses. Also bring a current medical insurance cards and a photo ID (if this does not show your current address, you must also bring a utility bill or other correspondence which shows your current address.)
Note: the photo ID is necessary because we are now required to comply with federal identity-theft prevention laws.
We recommend that you nap as long as possible to jump start your healing process.
Independent Physician at Medical Center Eye Clinic
655 Medical Center Drive NE
Salem, OR. 97301
Page 2


Patient Name
Surgery Eye:
Post-Op Appointment Date / Time
Cataract Post-Op Instructions
Use your eye drops on the schedule provided by your surgeon.
No lifting over 20 pounds for 1 week.
Do not rub your eye, or get anything in your eye, which can increase the chance of infection.
Avoid running the shower in your eye for 1 week. Bathe and shower with your eyes closed.
No hot tubs, swimming pools, bodies of water, saunas or tanning beds for 1 week.
No eye make-up or under eye cream for 1 week.
Do wear glasses or sunglasses during the day for comfort.
Wear your protective eye cover-ing (eye shield) as prescribed and avoid sleeping on the side that had been operated on.
If you are currently using drops for glaucoma continue all drops as directed.
Bring all eye drop medications to post-op appointments.
Call the office at (503) 581-5287 if you experience any pain, red-ness, or change in vision for the worse in the operative eye, or for any other concerns relating to your eye.
Eye Drop Medication
Instill 1 drop in the surgery eye for the medications as indicated below :
Instill drop 4 times daily in surgery eye only.
Instill drop 4 times daily in surgery eye only.
Instill drop 2 times daily in surgery eye only.
Instill drop 3 times daily in surgery eye only.
Instill drop 4 times daily in surgery eye only.
Instill drop 1 times daily in surgery eye only.
Independent Physician at Medical Center Eye Clinic
655 Medical Center Drive NE
Salem, OR. 97301
Page 3
SALEM LASER AND SURGERY CENTER
1330 Commercial St. SE
Salem, OR 97302
503-763-1973

FEE ESTIMATE

PATIENT NAME:

PLANNED PROCEDURE:

PROCEDURE DATE:

This information tool is to be considered an approximation of facility fees for the procedure identified above and does not cover fees for procedures not scheduled on this date.

SURGEON FEES
Billed seperately by your physician.

ANESTHESIA FEES
Billed seperately by your anesthesia practitioner; questions may be directed to: Anesthesia Associates Northwest, LLC
1-877-222-4217

SURGERY CENTER FEES
The facility billing office will contact you prior to surgery to let you know what your estimated patient portion will be. Billing questions may be directed to the CBO at 1-855-887-4997.

Co-payments are due at the time of your procedure. Co-payments accepted by check, credit card, or exact amount of cash only.

INSURANCE BILLING & STATEMENTS
We participate with many plans and will bill your insurance carrier accordingly. We also accept Medicare assignment.

Depending on your insurance plan and their payment guidelines, you will receive a statment after your surgery. Check your statement for the "Amount Due" box. That is the balance due by you. Call 1-855-887-4997, if you have questions about your surgery billing.

ASK US
Please do not hesitate to call us with any questions or comments you may have. We will assist you as best we can.


8/17     FEE ESTIMATE, CATARACT
Physician's Order Sheet
Patient Name:
PRE-OPERATIVE ORDERS
1.
Diagnosis:            
Mild/Moderate Glaucoma-        
2.
Procedure:           
       
       
3.
Admit to Salem Laser and Surgery Center
4.
Check Medication Reconciliation sheet for allergies.
5.
Routine admitting vital signs
6.
Nurse Anesthetist to evaluate patient if MAC
7.
Start saline lock. May use 2%, 0.1 to 0.2 ml for local anesthesia for insertion of IV needle.
8.
Place H&P in chart.
9.
PRE-OP MEDICATIONS:
  1.     Xanax (alprazolam) PO PRN for LenSx cases; dosage by physician preference:
    1.    For Drs. East, Neahring: 0.25mg for ALL patients.
    2.    For all other surgeons: 0.25mg for patients OVER 60, 0.50mg for patients 60 or UNDER.
  2.     Proparacaine 0.5% ophthalmic solution, 1-3 drops in operative eye PRN.
  3.     Give 1 drop of Compounded DILATING ophthalmic solution [contents below] in operative eye;
        repeat in 10 minutes PRN:
        -Tropicamide 1%
        -Phenylephrine 2.5%
        -Cyclopentolate 1%
        -Ketorolac 0.4%
        -Proparacaine 0.1%
10.
Check blood glucose level preoperatively on all insulin dependent patients.
11.
If listed, and/or patient reports EVER using an alpha adrenergic medication, follow physician orders listed below:
  1.     For Drs. East, Lapour, Dodd, Stice, Warner, Messenger: give Atropine Sulfate 1% ophthalmic solution,
        1 drop in operative eye; repeat in 5 minutes.
  2.     For Drs. Neahring and Gurdian: NO ATROPINE ORDERED.
  3.     Dr. Messenger ONLY: in addition to Atropine 1%, give 1 gtts phenylephrine 10% ophthalmic solution.
12.
Other
INTRA-OPERATIVE ORDERS
1.
Routine per preference card
2.
Other
POST-OP APPOINTMENT:
Date:  
Time:  
Signature:
MD
Date:
Time:
PHYSICIAN ORDER SHEET       Rev. 06/17
(PATIENT LABEL)
1330 Commerical St. SE
Salem, OR 97302-4206
Lens Order Sheet
Patient & Procedure
Patient Name:
Date of Birth:
Age:  
Date of Surgery:  
Surgeon:
Surgery:
Comment:
Lens
Lens Model
Diopter
STANDARD

STANDARD CLEAR

BACKUP
TORIC
SN6AT
TORIC CLEAR
SA6AT
MULTIFOCAL

PanOptix TFAT00
MULTIFOCAL TORIC
TFAT
ANTERIOR
CHAMBER
SPECIAL
ORDER
LenSx
Primary
Secondary
# Arcs
Depth
Diameter
Axis
Length






Additional Lens Models
Standard AMO
ReStor 3.0
ReStor 2.5
Symfony
Symfony Toric
ZCB00
SN6AD1
SN25TO
ZXR00
ZXT
PATIENT NAME LABEL

Board-Certified Ophthalmologist

Phone 503.581.5287  
Fax  503.386.1377  
CATARACT SURGERY WITH IOL (INTRAOCULAR LENS)

Patient Name:
DOB:
A cataract develops when the lens in your eye becomes cloudy. The lens is part of your eye that helps focus images. Cataracts can cause problems such as blurry or dulled vision, sensitivity to light and glare, and seeing shadows or ghost–like images.

Cataracts always get worse. Surgery is the only way to remove it. It is your choice when to have cataract surgery. Most people wait until their vision problems interfere with daily life. You can also decide not to have your cataract removed.

During cataract surgery, your eye surgeon will remove the cloudy lens. He will replace it with an IOL—intraocular lens, a clear plastic artificial lens. The most common is a monofocal (one focus) IOL. This helps improve vision at mostly just one distance, either near or far. You will probably need glasses to see clearly at other distances.

Cataract surgery only corrects vision problems caused by cataracts. This surgery cannot correct vision problems caused by glaucoma, diabetes, age-related macular degeneration, or other eye illnesses or injuries.

Many patients with cataracts also have astigmatism or presbyopia (eye problems that make it hard to see).
Astigmatism causes blurry vision. Normally, the clear window of the eye, the cornea, is round like a ball. If an eye has astigmatism, the cornea is more football–shaped. This blurs the focus.

Presbyopia makes it hard for the eye to focus at near. Most people get this as they age. People at any age who have cataract surgery with a monofocal IOL focused for distance vision will have some presbyopia. People with presbyopia might hold a book or menu at arm’s length to try to see it more clearly.

Glasses help astigmatism and presbyopia. If you want to wear glasses less often, the eye surgeon can put in a special IOL or do an extra procedure during cataract surgery to treat these eye problems.

You have to pay extra for special IOLs or extra surgical procedures. Medicare and private insurance do not pay for these. Your eye surgeon will let you know if you have astigmatism or presbyopia. Your eye surgeon will give you more information if you are interested in these treatments. You will be asked to sign another consent for them.


Cataract surgery is usually safe and successful. As with all surgery, there are risks (problems that can happen) with cataract surgery. While the eye surgeon cannot tell you about every risk, here are some of the common or serious risks:
Medical Center Eye Clinic
655 Medical Center Drive NE
Salem, OR. 97301
Page 1


Board-Certified Ophthalmologist

Phone 503.581.5287  
Fax  503.386.1377  
CATARACT SURGERY WITH IOL (INTRAOCULAR LENS)
•
•
Risks from cataract surgery include vision loss, blindness, or not getting the result you want. You could also have bleeding, infection, a droopy eyelid, or glaucoma (high eye pressure). You could get a detached retina. This is when the retina, at the back of the eye, pulls away from where it is attached. You may need surgery to fix the detached retina. Your eye may be injured by surgery or anesthesia. You may need another surgery later to take out pieces of the cataract that were not removed during the cataract surgery.

Risks from an IOL. The IOL may be too weak or too strong. The eye surgeon might not be able to insert the IOL of your choice. The eye surgeon may need to replace or reposition your IOL months or years after surgery.
•
•
•
•
Problems during surgery that need immediate treatment. Your surgeon may need to do more surgery right away or change your surgery to treat this new problem.

Anesthesia can cause heart and breathing problems. Very rarely, it can cause death. Anesthesia can also injure your eye and cause vision loss or double vision.

Other risks. There is no guarantee that cataract surgery will improve your vision. It is possible that cataract surgery or anesthesia may make your vision worse, cause blindness, or even the loss of an eye. These problems can appear weeks, months, or even years after surgery.

You may need to wear glasses after cataract surgery.

CONSENT. By signing below, you consent (agree) that:
•   You read this informed consent form, or someone read it to you.
•   You understand the information in this informed consent form.
•   The eye surgeon or staff offered you a copy of this informed consent form.
•   The eye surgeon or staff answered your questions about cataract surgery.
•   Your eye surgeon or staff have discussed presbyopia following cataract surgery and ways to treat it.
•   If you have astigmatism, the eye surgeon or staff discussed ways to treat it.
•   You understand that you may need to wear glasses after surgery.
(intraocular lens) in my eye.
Patient Signature
Date
Time
Witness Signature
Date
Time
Medical Center Eye Clinic
655 Medical Center Drive NE
Salem, OR. 97301
Page 2
MARCUS A. EAST, M.D.
JOHN G. DODD, D.O.
RYAN W. LAPOUR, M.D.
ADAM T. SHUPE, O.D.
(503) 581-5287
Co-Management Release Form
Patient Name:

I will be given an information sheet explaining the post-operative surgery instructions, appointments needed, and the care of my eye following surgery. This has been explained by my surgeon. l understand that l am to return to either my surgeon or regular ophthalmologist / optometrist following surgery for an appropriate period of time in order to ensure that my recovery is progressing normally.

Please choose one option below:

I have informed my surgeon that it will be more convenient for me to have my post-operative care preformed by my ophthalmologist/ optometrist when it is medically appropriate. l have discussed this program with my ophthalmologist / optometrist and he/she is willing to perform these services and consult with my surgeon as needed for my care. My ophthalmologist / optometrist also has agreed to provide my surgeon with a copy of my record after each post-operative visit.

My surgeon has assured me that l can contact his office at any time with any questions or for any problems, and if I choose to return to him at any time during the post-operative period, l may do so.

l have informed my surgeon that it will be more convenient for me to receive my post-operative care from him. It is my choice not to return to my ophthalmologist / optometrist for my post-operative care.

My Ophthalmologist / Optometrist:
My Surgeon:
Patient Signature:
Witness Signature:
Date and Time:
655 Medical Center Dr. NE
Salem, Oregon 97301
503.581.5287
Fax 503.386.1377
mceyeclinic.com
Patient:
Date of Birth:
Sx Date:
Co-Manage
Yes         No

Drops

OD

Date

OS

Date
EOM

PUPILS
MR
BAT
NV
PRESSURE


SLE
DILATE
EXAM AT PRE-OP
REFRACT FIRST EYE:
 

BP   P   R
PHYSICAL EXAMINATION
Mental Status:
Other
Heart:
Other
Lungs:
Other
Other:

Plan:      Schedule for surgery


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